What is the recommended care plan for a patient with a patella fracture?

Patella Fracture Care Plan

Immediate Assessment and Management

For patella fractures, initiate immediate multimodal analgesia before diagnostic workup, determine surgical versus conservative treatment based on displacement and extensor mechanism integrity, and systematically evaluate all patients over 50 for secondary fracture prevention.

Pain Management

• Provide appropriate pain management as soon as possible before starting diagnostic investigations 1
• Use multimodal analgesia with scheduled acetaminophen as first-line treatment 2, 3
• Consider regional nerve blocks for superior pain control 3, 4
• Avoid opioids as first-line agents in elderly patients due to increased risk of falls, delirium, and mortality 3, 4
• Document pain scores at rest and with movement before and after analgesia administration 2

Initial Diagnostic Workup

• Obtain anteroposterior and lateral radiographs of the knee as standard imaging 5
• Consider CT scan when available, as it frequently modifies both fracture classification and treatment choice by revealing fracture complexity not apparent on plain films 5
• Assess for displacement (>2-3mm step-off, >1-4mm separation) and extensor mechanism integrity 5, 6

Treatment Decision Algorithm

Conservative Management Indications

Undisplaced fractures with intact extensor mechanism can be treated nonoperatively 5, 6

• Immobilize with cast or brace 6
• Begin early mobilization as pain allows 1
• Initiate weight-bearing as tolerated to prevent immobility complications 3, 4

Surgical Management Indications

Surgical treatment is recommended for fractures that either disrupt the extensor mechanism or have more than 2-3mm of step-off and more than 1-4mm of displacement 5

Surgical Technique Selection

• For simple transverse fractures: Tension band wiring remains the most commonly employed technique 5, 6
• Modified approach without K-wires: Circumferential cerclage with figure-of-eight configuration achieves 92% of patients reaching 90 degrees active flexion within one week, with fracture union by 16 weeks and minimal complications 7
• For highly comminuted fractures: Partial patellectomy provides results similar to internal fixation when comminution precludes stable fixation 8
• Avoid cerclage wiring alone: This technique has a 29% infection rate in open fractures 8

Surgical Timing

• Perform surgery within 48 hours of injury when possible 1
• In hemodynamically unstable patients or those with severe associated injuries, consider delayed definitive surgery after stabilization 1

Perioperative Management (Especially for Elderly Patients)

Multidisciplinary Orthogeriatric Comanagement

To improve functional outcome and reduce length of hospital stay and mortality, orthogeriatric comanagement should be provided, especially in elderly patients 1

• Implement comprehensive geriatric assessment including 1, 3, 4:
  • Nutritional status evaluation and oral supplementation
  • Electrolyte and volume disturbances requiring correction
  • Anemia screening with appropriate transfusion thresholds
  • Cardiac and pulmonary comorbidities assessment
  • Cognitive function baseline and delirium risk evaluation
  • Complete medication review
  • Renal function assessment

Prevention of Immobility Complications

• Begin mobilization within 24-48 hours to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning 3, 4
• Implement pharmacologic VTE prophylaxis with low molecular weight heparin 3, 4
• Add mechanical compression devices if anticoagulation is contraindicated 4
• Implement multi-component delirium prevention including hydration management, sleep-wake cycle normalization, and cognitive orientation 4

Postoperative Care and Rehabilitation

Early Rehabilitation Protocol

• Physical training and muscle strengthening should begin immediately post-fracture 1, 4
• Supervised ambulation initially with fall prevention strategies 4
• Long-term continuation of balance training and multidimensional fall prevention 1

Hardware Considerations

• In most cases using traditional tension band fixation, hardware requires removal after fracture healing due to implant-related pain 5
• Modified techniques using circumferential cerclage with figure-of-eight configuration eliminate K-wire complications and may not require hardware removal 7

Secondary Fracture Prevention (Patients ≥50 Years)

Each patient aged 50 years and over with a patella fracture should be evaluated systematically for the risk of subsequent fractures 1

Risk Evaluation Components

• Review clinical risk factors 1
• DXA of spine and hip when feasible 1, 4
• Imaging of spine for vertebral fractures 1
• Falls risk assessment 1, 4
• Identification of secondary osteoporosis causes 1

Pharmacological Prevention

Pharmacological treatment should preferably use drugs that have been demonstrated to reduce the risk of vertebral, non-vertebral and hip fractures 1

• First-line agents: Alendronate or risedronate (generic bisphosphonates available, well-tolerated, low cost) 1
• Alternative agents for oral intolerance, dementia, malabsorption, or non-compliance: Zoledronic acid (intravenous) or denosumab (subcutaneous) 1, 4
• Ensure adequate calcium (1000-1200mg/day) and vitamin D (800 IU/day) supplementation, which reduces non-vertebral fractures by 15-20% 1, 2, 4
• Monitor regularly for tolerance and adherence 1, 4

Implementation Structure

• Designate a local responsible lead (coordinator, often well-educated nurse) to coordinate secondary fracture prevention 1, 4
• Establish liaison between orthopaedic surgeons, rheumatologists/endocrinologists, geriatricians, and general practitioners 1, 4
• Provide patient education about disease burden, risk factors, follow-up, and treatment duration 1, 4

Common Pitfalls to Avoid

• Do not delay pain management waiting for imaging - provide analgesia immediately 3
• Do not use opioids as first-line in elderly patients - heightened risks of falls, delirium, and mortality 3, 4
• Do not rely solely on plain radiographs for complex fractures - CT scan frequently changes classification and treatment 5
• Do not use cerclage wiring alone - associated with high infection rates 8
• Do not immobilize excessively - early mobilization prevents complications 3, 4
• Do not neglect secondary fracture prevention in patients ≥50 - patella fractures are fragility fractures requiring systematic evaluation 1, 4